收肌管阻滞联合腘动脉-膝关节囊后间隙阻滞或胫神经阻滞在全膝关节置换术中的应用

Application of adductor canal block combined with infiltration between the politeal artery and capsule of the posterior knee or tibial nerve block for patients undergoing total knee arthroplasty

目的比较收肌管阻滞(ACB)联合腘动脉-膝关节囊后间隙阻滞(IPACK)或选择性胫神经阻滞(TNB)用于全膝关节置换术的镇痛效果及对运动功能的影响。方法选择2020年4—6月行全膝关节置换术老年患者60例,男28例,女32例,年龄65~84岁,ASAⅡ或Ⅲ级。采用随机数字表法分为两组:IPACK组(I组)和TNB组(T组)。I组于术前采用含肾上腺素0.1 mg的0.25%罗哌卡因20 ml行IPACK,T组于术前采用含肾上腺素0.1 mg的0.25%罗哌卡因20 ml行TNB。I组与T组完成IPACK或TNB后行ACB,并留置神经周围导管,术后连接患者自控神经阻滞镇痛泵。术后VAS疼痛评分>4分时,患者按压镇痛泵,30 min未缓解,皮下注射羟考酮5 mg进行补救镇痛。记录术后4 h腓总神经运动阻滞情况及术前、术后24、48、72 h静息、运动时VAS疼痛评分。记录术后1~3 d患者主动屈膝最大角度及步行距离。记录术后72 h内患者补救镇痛及不良事件发生情况。结果与T组比较,I组腓总神经运动阻滞率明显降低(P<0.05);术后1、2 d步行距离明显增加(P<0.05)。两组不同时点静息、运动时VAS疼痛评分、补救镇痛率、术后3 d步行距离及术后1~3 d主动屈膝最大角度差异无统计学意义。结论ACB联合IPACK或TNB均可为全膝关节置换术患者提供有效地术后镇痛,但IPACK对运动功能影响小于TNB。

Objective To compare the effect of adductor canal block(ACB)combined with infiltration between the politeal artery and capsule of the posterior knee(IPACK)or selective tibial nerve block(TNB)for patients undergoing total knee arthroplasty(TKA),so as to optimize the strategy of analgesia management.Methods Sixty patients scheduled for TKA,28 males and 32 females,aged 65-84 years,ASA physical statusⅡorⅢ,were randomly divided into two groups:IPACK group(group I)and TNB group(group T).IPACK was performed with 20 ml 0.25%ropivicaine containing 0.1 mg epinephrine before operation in group I,and selective tibial nerve block was performed with 20 ml 0.25%ropivicaine containing 0.1 mg epinephrine before operation in group T.ACB was performed and peripheral nerve catheter was inserted after IPACK or TNB in groups I and T.Patient controlled nerve block pump was connected to the catheter after operation in both groups.When VAS score>4 score and pain was not relived 30 minutes after pressing patient controlled nerve block pump,oxycodone hydrochloride 5 mg was subcutaneously injected as rescue analgesic.The motor block of common peroneal nerve 4 hours after operation and VAS score 24,48 and 72 hours after operation were recorded.The maximum range of knee motion and the walking distance were recorded on day 1-3 after TKA.The analgesic remedy and adverse events were recorded.Results Compared with group T,the motor block of common peroneal nerve was lower in group I(P<0.05).Compared with group T,the walking distance on day 1-2 after TKA were increased in group I(P<0.05).The VAS score 24,48 and 72 hours after operation during rest and movment,analgesic remedy,the walking distance on 3rd day after operation,and the maximum range of knee motion on day 1-3 after TKA was not significantly different between groups I and T.Conclusion Both IPACK and TNB combined with ACB can provide effective postoperative analgesia for patients undergoing TKA.IPACK has less effect on motor function,which is superior to TNB.Therefore,it is recommended that ACB combined with IPACK should be the optimized strategy of analgesia management.